| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,073 |
999 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
71 |
$25K |
| D9110 |
|
454 |
435 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
642 |
$15K |
| D1110 |
Prophylaxis - adult |
346 |
344 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
678 |
637 |
$10K |
| D4355 |
|
124 |
121 |
$7K |
| D0274 |
Bitewings - four radiographic images |
145 |
144 |
$4K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
125 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
53 |
$886.56 |
| D1120 |
Prophylaxis - child |
28 |
27 |
$672.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$493.92 |